New York Presbyterian-Brooklyn Methodist Hospital's Quality Improvement Project Targeting High A1C Levels.

Quality Improvement Success Stories are published by the American Diabetes Association in collaboration with the American College of Physicians and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes a Brooklyn, NY, hospital's initiative to reduce high A1C rates among its patients.

A case of ventricular standstill in a patient with acute gastrointestinal bleeding.

Ventricular stand still is an electrophysiologic phenomenon characterized by the absence of ventricular activity or contraction. It is the result of the lack of impulse formation in ventricles (absence of idioventricular automaticity) or the failure of impulse transmission to ventricles (conduction disturbance) [1]. It is an uncommon condition that can affect a wide range of age groups with life threatening consequences. There are no set guidelines on the treatment of ventricular standstill - swift and sound clinical judgment is required. The condition should be treated as a cardiac arrest, with resolution of precipitating factors. Here we present a case of a 59-year-old man with multiple comorbidities, who presented with massive gastrointestinal hemorrhage and recurrent episodes of ventricular standstill during hospitalization, with his immediate treatment and stabilization.

Atypical Presentation of Acute Coronary Syndrome and Importance of Wellens' Syndrome.

BACKGROUND Acute coronary syndrome (ACS) is a common and potentially life-threatening condition encountered in emergency departments. Despite its dreaded nature, nearly one-third of ACS present without chest pain and may mislead clinicians. Additionally, Wellens' syndrome is a pre-infarction stage of significant proximal left anterior descending (LAD) artery stenosis, which can lead to extensive anterior wall myocardial infarction without timely intervention.  CASE REPORT We report the case of a 74-year-old woman presenting with isolated throat pain and Wellens' pattern in the initial EKG, which prompted the proper workup and management. Subsequently, coronary angiogram revealed more than 90% occlusion of the proximal LAD artery, and a drug-eluting stent was deployed. The patient did well after the procedure and the follow-up at 2 weeks after discharge was uneventful.   CONCLUSIONS This case highlights the importance of awareness of atypical presentation of ACS and importance of Wellens' syndrome. We also discuss the incidence of craniofacial symptoms of ACS, and the epidemiology, pathophysiology, management, and prognosis of Wellens' syndrome.

Benefit and risk of primary thromboprophylaxis in ambulatory patients with advanced pancreatic cancer receiving chemotherapy: a systematic review and meta-analysis of randomized controlled trials.

As vascular thromboembolism (VTE) is a leading cause of death in cancer patients, it has been postulated that primary thromboprophylaxis (PTP) in cancer patients might improve survival by reducing VTE occurrence. We performed a systemic review and meta-analysis of randomized controlled trials (RCTs) to investigate the benefit and risk of PTP with low-molecular-weight heparins (LMWHs) in ambulatory advanced pancreatic cancer (APC) patients receiving chemotherapy. We undertook a literature search using MEDLINE and EMBASE databases through May 2015. RCTs with reduction in symptomatic VTE as a primary or secondary endpoints were included. Mantel-Haenszel method was used to estimate the pooled event-based risk ratio as well as the pooled absolute risk difference with 95% confidence interval (CI). Seven hundred and thirty-eight APC patients were eligible for analysis. PTP lasted 3-6 months. The crude VTE incidence was 2.1 and 11.2% in LMWH and in control groups, respectively (risk ratio, 0.18; 95% CI, 0.083-0.39; P < 0.0001). The absolute risk difference in VTE was -0.092 (95% CI, -0.127 to -0.057; P < 0.0001), with an estimated number needed to treat of 11 patients to prevent one symptomatic VTE event. The pooled risk ratio for major bleeding was 1.25 (95% CI, 0.48-3.3, P = 0.65). Although these findings are encouraging to deploy PTP in APC patients receiving chemotherapy, uncertainties remain as to its survival benefit, optimal PTP duration, type and dose of LMWH, and costs of care. Therefore, adequately powered randomized phase III studies are warranted to address these questions.

A Rare Concurrence of Leiomyomatosis Peritonealis Disseminata, Leiomyosarcoma of the Pelvis and Leiomyomatous Nodule of the Liver.

Leiomyomatosis peritonealis disseminata (LPD) is a rare entity that is characterized by the presence of multiple subperitoneal or peritoneal smooth muscle nodules throughout the peritoneal surface mimicking a malignant process. LPD follows a benign course in general, and it is often found incidentally during abdominal surgery. There have been reported cases of LPD with malignant degeneration although the association is uncertain. Concurrent finding of LPD and leiomyosarcoma of the pelvis is very rare that could be coincidental, malignant transformation of LPD to leiomyosarcoma, or progression of undetected primary leiomyosarcoma. There are only a few previously reported cases in the literature. Herein, we report a case of 56-year-old woman with a history of leiomyoma of uterus who presented with progressive abdominal swelling secondary to mass lesions in the pelvis. The patient underwent exploratory laparotomy and debulking of the tumors, and the histologic examination of the tumors revealed coexistence of LPD and leiomyosarcoma. After recovery from the operation, core needle biopsy of the superficial, residual liver mass was obtained to investigate potential liver metastasis, and the histopathologic findings are consistent with leiomyoma which represents the first simultaneous occurrence of LPD, leiomyosarcoma, and leiomyomatous nodule of the liver.

A predictable but life-threatening complication of hydroxyurea in a patient with sickle cell anaemia: an experience learned from a Jehovah's Witness.

It is well known that hydroxyurea can cause pancytopaenia secondary to bone marrow suppression, which is reversible with short-term discontinuation of the therapy. However, it is important to note that bone marrow suppressive effects caused by hydroxyurea could be easily potentiated in patients with sickle cell anaemia complicated by chronic kidney disease (CKD). We present a case of a Jehovah's Witness with sickle cell anaemia, who developed severe bone marrow suppression due to the combined effects of hydroxyurea and CKD, resulting in a prolonged recovery period after discontinuation of hydroxyurea.

Sister Mary Joseph Nodule: A Rare Presentation of Squamous Cell Carcinoma of the Cervix.

BACKGROUND: Sister Mary Joseph nodule refers to metastatic malignancy of the periumbilical region. Umbilical metastasis is an indicator of advanced malignant disease. CASE REPORT: We present the case of an 88-year-old patient presenting with postmenopausal vaginal bleeding, inguinal lymphadenopathy, and physical findings of a palpable umbilical nodule (Sister Mary Joseph nodule). Further workup was consistent with metastatic squamous cell carcinoma of the cervix. CONCLUSION: Because Sister Mary Joseph nodule may be the only manifestation of underlying malignancy, thorough physical examination plays an important role in diagnosing the malignancy in a more confined state that may have a positive impact on the patient's length of survival.

Predictors of plasma cell disorders among African American patients: a community practice perspective.

African Americans have two- to three-fold higher incidence of multiple myeloma and MGUS compared to other ethnic groups in the USA. Some physicians often perform diagnostic evaluations for plasma cell disorders (PCD) in African American patients on the basis of hematological abnormalities (thrombocytopenia, leucopenia, etc.) even in the absence of traditional triggers such as anemia, renal impairment, hypercalcemia, hyperglobulinemia, and lytic bone disease. Whether these nontraditional triggers have any significant association with PCD in African American population is not known. In addition, whether this approach could detect more asymptomatic PCD than black population prevalence is questionable. Moreover, the association between traditional triggers and PCD particularly in blacks has not been clearly delineated. Hence, we have carried out a retrospective study in an attempt to answer these questions. Two hundred fifty-four patients were eligible. Multiple myeloma workup based on parameters other than traditional triggers did not detect more asymptomatic PCD than what is expected of black population prevalence (p = 0.19). Of traditional triggers, the finding of only anemia or hyperglobulinemia seemed to be nonspecific in black population (p = 0.17 and 0.85, respectively). However, the presence of serum creatinine >2 mg/dL or corrected serum calcium >10.5 mg/dL or a combination of traditional triggers appeared to be strongly predictive of PCD (odds ratio of 6.9, 4.2, and 3, respectively). The number of trigger variables was positively correlated with the likelihood of PCD (p < 0.001). Light-chain-only PCD, renal disease, and abnormal free light chain ratio seemed to be higher in black patients than their white counterparts.

Prevention and treatment of venous thromboembolism with new oral anticoagulants: a practical update for clinicians.

Traditional anticoagulants, such as warfarin and enoxaparin, have several limitations, including parenteral administration, need for laboratory monitoring, and ongoing dose adjustment, which may limit optimal patient care. Newer oral anticoagulants, such as direct thrombin inhibitors (e.g., dabigatran etexilate) and direct factor Xa inhibitors (e.g., rivaroxaban, apixaban, and edoxaban), have been developed to overcome these drawbacks, and thereby improve patient care. Several of these agents have been approved for use in the prevention and treatment of venous and/or systemic thromboembolism. The objective of this paper is to provide an overview of the available clinical trial data for these new oral anticoagulants in the prevention and treatment of venous thromboembolism and a practical update for clinicians.

A rare case of intracerebral hemorrhage complicating heparin-induced thrombocytopenia with thrombosis: a clinical dilemma ameliorated by novel use of plasmapheresis.

We report a case of heparin-induced thrombocytopenia with thrombosis type 2 (HITT 2) that was first complicated by intracerebral hemorrhage (ICH) and later by deep venous thrombosis (DVT). HITT 2 was initially managed conventionally with argatroban, which was stopped when ICH was discovered. The size of ICH increased despite attempts to increase platelet count by platelet transfusions. At this point of the clinical dilemma, plasma exchange was utilized effectively to recover the platelet count and deter ICH progression. The clinical course was later complicated by DVT, for which fondaparinux was given. This case represents a rare clinical scenario of HITT 2 resulting in progressive ICH that excluded the use of antithrombotic agents as part of HITT therapy. We believe that the use of plasmapheresis as a salvage procedure in such situations is effective and life-saving. Physicians should be aware of plasmapheresis as a therapeutic option in HITT 2 in cases in which anticoagulation is contraindicated.